Unlock hundreds more features
Save your Form to the Dashboard
View and Export Results
Use AI to Create Forms and Analyse Results

Forgot Password?
Get Started
OR
Sign UpLogin With Facebook
Sign UpLogin With Google

Professional Counselling Informed Consent Form Template

Streamline Your Counseling Process with a Comprehensive Consent Form

Navigating the complexities of client consent can be challenging for therapists like you. This informed consent form template is designed specifically for counseling professionals, providing a clear and ethical framework that ensures your clients understand their rights and responsibilities. With this template, you can boost client trust, simplify administrative processes, and ensure compliance with legal requirements, all while saving time in your practice. Explore the live template to enhance your client interactions today.

Use this Template (FREE) Live Preview
Client full name
Date of birth
Email address
Mobile phone number
Mailing address
Preferred contact method
Phone call
Text message
Email
No preference
Is it okay to leave a voicemail at this number?
Yes
No
Is it okay to send SMS text reminders?
Yes
No
Is it okay to email appointment reminders and updates?
Yes
No
Emergency contact full name
Emergency contact phone number
Emergency contact relationship to you
Parent/Guardian
Spouse/Partner
Sibling
Friend
Colleague
Other
Please Specify:
Is the client under 18 years of age?
Yes
No
Are you the parent or legal guardian completing this form?
Yes
No
Parent/guardian full name
Parent/guardian phone number
Parent/guardian email address
Relationship to client
Parent
Legal guardian
Other caregiver
Other
Please Specify:
Main reason for seeking counseling
Are you currently receiving counseling or mental health treatment from another provider?
Yes
No
Are you currently taking any psychiatric medications?
Yes
No
Are you currently experiencing thoughts of harming yourself or others?
Yes
No
Do you need any accommodations to participate in sessions?
Yes
No
If you would like to specify any accommodations, please describe
Preferred session format
In person
Telehealth (video)
Phone
No preference
Preferred general session times
Weekday mornings
Weekday afternoons
Weekday evenings
Weekends
I understand the nature and purpose of counseling, including potential benefits and limitations.
Yes
No
I understand that participation is voluntary and I may pause or stop at any time.
Yes
No
I understand confidentiality and its legal limits (risk of harm, abuse/neglect, court order, supervision/consultation, and other legal requirements).
Yes
No
I consent to receive counseling services from this provider.
Yes
No
I understand this service is not a crisis or emergency service.
Yes
No
I consent to receive services via telehealth when appropriate and understand the associated risks and limitations.
Yes
No
I consent to my counselor consulting with supervisors or colleagues to support my care, with my identifying information shared only as permitted by law.
Yes
No
I acknowledge that services are provided free of charge and that no insurance will be billed.
Yes
No
I acknowledge the scheduling, cancellation, and no-show expectations provided to me.
Yes
No
I acknowledge that I have received or had the opportunity to review the privacy policy/notice of privacy practices.
Yes
No
I consent to be contacted with appointment reminders and scheduling updates using the methods I approved above.
Yes
No
I consent to the use of my de-identified information for program evaluation and quality improvement.
Yes
No
Name of person giving consent (type full legal name)
Signature
Date of signature
Relationship to client for consent
Self (client)
Parent/Legal guardian
Other
Please Specify:
{"name":"Client full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Client full name, Date of birth, Email address","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a professional counselling informed consent form for FormCreatorAI article.

When to use this form

Use this template before a first session, when you resume care after a break, or when you change a treatment plan or move to telehealth. It fits private practice, school counseling, community agencies, and employee programs. You document services, risks and benefits, confidentiality limits, fees, scheduling, and how you communicate, so clients know what to expect and can make an informed choice. For typical outpatient settings, adapt a Therapy informed consent form. If you run groups, pair it with a Group therapy informed consent form to explain group norms, privacy limits, and attendance expectations.

Must Ask Professional Counselling Informed Consent Questions

  1. What services will you receive, and which therapeutic approaches will we use?

    This sets clear expectations about scope, methods, and goals so clients can decide if the fit is right. It prevents misunderstandings about modalities, boundaries, and what is outside the service.

  2. What are the potential benefits, risks, and alternatives to treatment?

    Stating upsides and downsides supports informed choice and accountability. It also surfaces safety concerns and accommodations you may need to plan for.

  3. What are the limits of confidentiality and how may your information be shared?

    Clients need to know legal exceptions (risk of harm, abuse, court orders) and how team consultation works. If you may use de-identified material for training or studies, add a Research consent form to document that separate permission.

  4. Do you consent to telehealth, electronic communications, and e-signature for this consent?

    This confirms channels (video, email, text), privacy risks, and your response times, reducing miscommunication. For remote signing, reference the Electronic informed consent form to collect consent securely.

  5. What are our fees, insurance billing practices, and cancellation or no-show policy, and do you accept them?

    Clear financial terms reduce payment disputes and last-minute cancellations. They also help clients plan treatment that fits their budget and availability.

More Forms

Copy/Edit Form Send to Recipients Make a Form w/AI Form Builder Must Ask Questions
  • 100% Free - No Catches
  • Collect Responses Today
  • Tailor to your Look & Feel